Two of These Things Belong Together: Evidence Based Treatment, Evidence Based Practice, Evidence Informed Intervention

 

Yes, although all these things in my title have the word “evidence” in their names, one is different from the others. The differences hinge on what people mean by evidence and its implications, and this is a real question, not a version of asking what “is” is.

Under different circumstances, “evidence” can be what my neighbor tells me happened on our street, or some material that a judge decided to accept in court over the protests of one party to a suit. It can also be information that has been collected according to the rules set by a group of scientists whose work is relevant to the topic.

Since the 1990s, medical specialists and psychologists have focused a good deal of energy on creating evidence based medicine and evidence based psychological treatments. They have used the term evidence based treatments (EBTs; sometimes called empirically-supported treatments, ESTs) to describe medical or psychological interventions that have been shown to be safe and effective through information collected according to established research rules. EBTs are treatments that have been shown to be effective in treating particular conditions by at least two studies that use randomized controlled trials or clinical controlled trials. At least one study needs to be done by independent researchers, not people involved in the method itself. There are a number of other requirements for these studies, for example that the people evaluating the outcome of a treatment should be “blind” to (unaware of) which clients received the treatment and which did not. Readers can find further descriptions of the rules of research at www.effectivechildtherapy.org , a website sponsored by Division 53 (Clinical Child Psychology) of the American Psychological Association.

Although this point is not always made clear, it is also generally considered that EBTs will not be potentially harmful treatments (PHTs). It’s well understood in medicine that a powerfully effective treatment may have unwanted adverse side effects, and such treatments have to  be chosen with the understanding that there is a risk/benefit ratio to be considered. Psychologists have only fairly recently begun to consider that a psychological treatment can have adverse effects as well as—or even instead of—beneficial ones. There is still too little known about adverse events of psychotherapies to make it easy to calculate risks and benefits of treatments, but a treatment with a known potential for harm would presumably not be considered an EBT at this point.

EBTs are the ones that “just don’t belong here” out of the.group of three in my title. How are evidence based practice (EBP) and evidence informed intervention (EEI) different from EBTs? Why is it important to consider the differences?

To answer the last question first: although psychologists and other mental health professionals have been encouraged to strive to use EBTs by their national professional organizations, they do not always do so. One very practical reason is that the research has not been done to provide a clear evidence basis for all psychosocial treatments. In fact, if people did not use treatments that are currently without a clear evidence basis, no data could be collected to show whether or not those treatments are demonstrably safe and effective. (However, when such treatments are used, it should be made clear that they are experimental treatments whose effectiveness has not been decided.)

A second practical reason for failure to use EBTs is that such treatments require very specific training. They are “manualized”—that is, there are prescribed ways of handling the events and timing of treatment. People trained to carry out EBTs must go through an extensive program that makes sure that their use of the treatment method is very close to the intervention whose outcome was tested empirically. Such training can be expensive in terms of time and other resources and is not available to every mental health practitioner.

But there are other reasons for failure to use EBTs, as well as the practical points. Mental health professionals may in many cases be people who feel that they know how to help others psychologically, that their personalities and compassion are as or more important than the precise methods they use. Like physicians who may prescribe a medication “off-label”, mental health professionals may feel that they have the authority and the responsibility to alter the way therapy is done, to personalize it in ways that they feel work for themselves and for their clients.

EBPs and EEIs are the results of this last reason, as well as of the scarcity of EBT resources. In both of these approaches (EBP or EEI), the idea is that a practitioner looks to the best available empirical research on therapies and chooses treatment from those, while also considering a client’s preferences and the therapist’s own experience, or “practice wisdom”.  There are, however, some flaws in  this approach. The first is that the best available research may not be at EBT level.   For example, none of the various parental alienation treatments have evidence at the EBT level, though there is published outcome research with weaker designs and implementation. To use the EBP language, this is the best available evidence—yet it is not at the level psychologists are encouraged to use, nor are these interventions apparently presented as experimental in nature. (On the contrary, PA advocates insist that they are supported by evidence adequate for admissibility in family courts, rather than acknowledging the level of evidence available.)

It is quite understandable that practitioners choose the EBP approach when there are no EBTs available for use. But—when there are EBTs, as there are in many situations involving children’s mood or behavior, there are fewer reasons to bring in “practice wisdom” and client preferences.

Evidence informed interventions (EEIs) use the same preference and wisdom factors as EBP. But they also argue that the quantitative studies used in EBT work cannot give information from the patient’s perspective, for which they consider qualitative and mixed methods research to be most important. These types of research are expensive in time and resources and thus often use small numbers of participants, making it difficult to be sure about results and also making it hard for other researchers to replicate. A recent book on custody and parenting coordination, “Evidence-informed interventions for court-involved families” (edited by Lyn Greenberg, Barbara Fidler, and Michael Saini), presses the EEI approach rather than encouraging more stringent research designs.

According to an Australian source (facs.nsw.gov.au) an EEI approach means using research evidence (level not stated), lived experience and client voice, and professional expertise in mking treatment decisions. The nature of the research evidence is not mentioned (and I have to wonder whether there can be experience that is not “lived”?), nor is there any discussion of the proportions of these sources practitioners should use in their decision-making. EEI proponents, in my opinion, see psychotherapy as an art rather than a science and believe that family events in particular are too complex to be approached effectively on the basis of EBT-level outcome research. I cannot say that they are necessarily quite mistaken in this view, but I would say that art should not be presented as ”evidence” in the scientific sense.

Advocates of EBP and EEI have on their side the practical facts I mentioned earlier—that EBTs are not always available , and that if only currently-known EBTs are used, we can never have any more EBTs identified. Given that these issues are important, however, there would appear to be no reason to withhold from courts and clients the fact that EBP/EEIs should be identified as “experimental” for the simple reason that they are not EBTs. The failure of proponents of these non-evidence-based treatments to identify their methods appropriately leads me to question their reasons for stressing preferences and experience over evidence. An attendee at a conference recently posed for me the question: isn’t it important to provide some treatment when there is a problem? I think it is not—unless it has been demonstrated that the treatment is safe and effective. Otherwise, is the practitioner simply deciding to use a treatment because he or she can do so and wants to do something, perhaps has even told the client or a court that he or she can help?

These are tangled webs, I am afraid, and I do not claim to know why people choose EBP/EEI and fail to say this is what they are doing. What I do know is that the word “evidence” in EBT, EBP, and EEI should not be taken to have the same meaning at all times.